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Posted February 4, 2013 07:18 pm

Feds give go-ahead for Medicaid managed care plan

Federal health officials have approved a key part of Florida's effort to transform its Medicaid program, clearing the way for tens of thousands of seniors across the state to move into managed-care plans.

The approval, announced Monday, means that Medicaid-eligible seniors who need long-term care likely will startenrolling later this year in HMOs and another type of health plan known as a "provider service network." The long-term care changes are the first phase of a controversial proposal to shift Medicaid beneficiaries statewide into managed care.

A basic concept of the long-term care changes is that managed-care plans would provide services to seniors at home or in their communities, if possible. In doing so, many seniors would be able to stay out of nursing homes, or at least postpone the need to go into such facilities.

Senate Appropriations Chairman Joe Negron, a Stuart Republican who played a key role in drawing up the Medicaid changes, said nursing homes will continue to play an important role in the Medicaid system. But he said seniors want to be able to "age in place" in their homes and communities and only go to nursing facilities when necessary.

"Now, it gives us the ability with Medicaid to provide these options in the community for seniors,'' Negron said.

The senior-advocacy group AARP Florida vowed Monday to be "watchdogs" as the new system is put in place.

"Florida elected officials have said they are pushing this reform effort forward because they want to assure the highest quality of care for frail and vulnerable Floridians under Medicaid,'' AARP Florida State Director Jeff Johnson said in a prepared statement. "AARP Florida will hold them to their word."

Gov. Rick Scott and the Republican-controlled Legislature approved wide-ranging bills in 2011 aimed at shifting to a statewide managed-care system in Medicaid. The plan was to make the changes in two phases --- first for seniors who need long-term care and then for the broader Medicaid population.

While many Medicaid beneficiaries already enroll in managed-care plans, backers of a statewide system argue it would help hold down Medicaid costs and better coordinate services for beneficiaries. But critics have long argued that the shift will result in managed-care plans squeezing care provided to low-income people.

Such Medicaid proposals require approval by the federal Centers for Medicare & Medicaid Services before they can take effect. The federal government faced a Thursday deadline for ruling on the long-term care proposal, after Florida gave notice late last year that it wanted to start a 90-day "clock" to compel a decision.

No such deadline exists for the changes affecting the broader Medicaid population, and it remains unclear when federal officials will make a decision. State Medicaid director Justin Senior told lawmakers in December that the Agency for Health Care Administration had focused first on getting approval for the long-term care portion of the changes.

Scott sent a letter Monday to U.S. Department of Health and Human Services Secretary Kathleen Sebelius expressing appreciation for approval of what is known as a Medicaid "waiver" for the long-term care changes. But he also pressed to get approval for the shift affecting the broader Medicaid population.

"Now, our most urgent need is the immediate approval of our second pending waiver, which relates to the statewide Medicaid managed-care program,'' Scott wrote. "This second waiver will give us additional flexibility within the current Medicaid program, and it supports our goal of improving the cost, quality and access to health care for all Florida families."

Scott met last month with Sebelius and has appeared to try to connect the state's managed-care proposals with a separate issue about whether Florida will expand Medicaid eligibility under the federal Affordable Care Act. The federal government wants states to expand eligibility as a way to provide health coverage for more people.

But Greg Mellowe, policy director for the patient-advocacy group Florida CHAIN, said it will be harder for the state to get approval of the broader managed-care proposal. That proposal would build off a highly controversial Medicaid managed-care pilot program that operates in five counties.

"The fact that the managed long-term care waiver was approved in no way indicates that approval of the broader statewide Medicaid managed-care waiver can be justified or will be forthcoming,'' Mellowe, whose group has been highly critical of the managed-care proposal, wrote in an email.

The state Agency for Health Care Administration has already gone through a lengthy contracting process to choosehealth plans that would provide long-term care services to seniors. That process involved competitive bidding in 11 regions of the state and led to AHCA awarding contracts to American Eldercare, Sunshine State Health Plan, United HealthCare of Florida, Coventry Health Care of Florida and Amerigroup Florida.

AHCA hopes to start using the new long-term care system as early as August in the Orlando area and gradually move into other areas of the state. But enrollment could be delayed in three regions --- the western Panhandle, the Big Bend and Palm Beach County and the Treasure Coast --- because of protests by losing bidders.

The Centers for Medicare & Medicaid Services sent a letter to the state Friday, approving the long-term care changes effective July 1. The approval is for three years, expiring June 30, 2016, with the state able to request renewals "by providing evidence and documentation of satisfactory performance and oversight."

Michael Garner, president of the Florida Association of Health Plans, said moving to the long-term care system will require an extensive education effort for seniors and family members who will choose between managed-care plans. Like Negron, Garner said nursing homes will continue to play an important role, but he said he hopes the new system will help get people into the "lowest-cost settings that are preferable for them and their families."